COVID-19 Telehealth Best Practices

COVID-19
Telehealth
Best
Practices
MARLENE M.
MAHEU, PHD
EXECUTIVE
DIRECTOR
TELEBEHAVIORAL
HEALTH
INSTITUTE
CONTACT@
TELEHEALTH.ORG
619-255-2788
Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Disclaimer/Disclosure
 GOAL: Our goal is educational only. No warranty, guarantee,
or representation is made as to the accuracy or sufficiency of
the information contained in our presentation for your specific
circumstance.
 YOUR PART: You are encouraged to seek practice-specific
advice from your legal, regulatory, ethical and malpractice
bodies before offering any online services or programs to
consumers. Get all such opinions in writing, and have your
informed, local, legal counsel review them for their full
significance.
 I have no conflicts of interest with any groups identified in this
training.
Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights
reserved.

Issues involved with COVID-19
are complex, fact-specific and
state-specific. They will require
legal expertise that I cannot
provided in this presentation.
I do not, and cannot, provide legal
advice. The information that I
present does not constitute and
should not be relied upon as legal
or ethical advice and should not
be used as a substitute for
obtaining personal legal advice
and consultation prior to making
decisions about your work.

CME or
CE
 You must complete a course
evaluation and post-test to unlock
and print a Course Completion
Certificate for your licensing board
 To purchase a CME or CE, visit this
page: https://telehealth.org/covid to
access the course and handouts,
then select the option to purchase
CME or CE from within that
dashboard
 Your will see one for all the types of
CME and CE offered

Please
Interact
 This was event is designed to
be a workshop –we can
interact
 Please contribute to the group
discussion
 The chat room is open for
everyone to see
 I will read your questions and
as much of the answers as
possible
 If you get out of hand, I will
remove you from the room and
refund your fees…

Today’s Webinar
The Internet Is Straining
PLEASE
UNDERSTAND
. YOU MAY
NOT HEAR OR
SEE
EVERYTHING.
INTOLERAN
T
RESPONSE
S TO
FAILING
TECH
DON’T
HELP
IF YOU
CANNOT
SEE ALL OF
THIS
EVENT, IT
WILL BE
RECORDED
IF THE
RECORDING
IS NOT
PERFECT,
PLZ KNOW
THAT WE ARE
TRYING

Make a To-Do List
Optimize Your Learning
1. Mute your phone, turn off texts and
emails, lock your door
2. Organize yourself by
3. making a to-do list as we go
4. Rank order your to-dos by priority
5. Consider meeting with like-minded
colleagues to discuss your
implementation plan

C1994-2020TelebehavioralHealthInstitute,LLCAllrightsreserved.

C1994-2020TelebehavioralHealthInstitute,LLCAllrightsreserved.
Polling Question #1

Poll
My technical
incom-
petence will
show
I will make a
clinical
mistake
I won't get
paid
I can't
control the
other site

Attitude
 Reflect on what’s happening worldwide
 Share views with trusted colleagues
 Self-discipline
 Stay sober
 Get and share the facts to reduce unneeded
anxiety
 Read “The Story of a Coronavirus,” New York
Magazine

Client/Patient Education
You need to check in more Technology is unforgiving.
Learning curve is steep.
Can create anxiety
t

This video conference is
not recorded
Technical specifications are
to be supplied by your
video vendor. Pass these
along to your clients

Technical specifications are
to be supplied by your
video vendor. Pass these
along to your clients.
Check your Internet speed
to make sure your
connection is adequate.

Cons
MORE MISTAKES
BECAUSE YOU
HAVE LESS
INFORMATION
“REPEAT IF I’M
NOT GETTING IT”
LET’S GO
SLOWLY
EXTRA CAUTION
NEEDED

CLINICAL
EVALUATION
AND CARE
(TBH Domain I)
Evaluation & Treatment
(Subdomain I.A)
C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Fundamentals of Telehealth
 The fundamentals of
responsible clinical practice do
not change with telehealth.
 Good clinical practice remains
the same regardless of delivery
vehicle.
 Adoption is changing

Right now, we are experiencing
forced adoption.
However, whether you use video,
telephone, text, email, apps,
artificial intelligence, remote patient
monitoring or any other tech, you
are responsible through your legal
and ethical codes to maintain the
same quality of care as in-person.

With integrity, you have
nothing to fear, since you
have nothing to hide.
― Zig Ziglar

Telehealth is much like
driving a car. It can take
a few months of regular
practice to learn and
remember safe
response sets, develop
reflexes, etc.

Telehealth is similar. However,
right now, in this extraordinary,
worldwide state of emergency, so
many clinicians are untrained that
the rules must be temporarily
relaxed.
Keeping clients/patients safe is
more important than attending to
other safety rules such as privacy
right now.

Role of Good
Clinical
Practice &
Work Ethics
 Practitioners have
traditionally been free to
practice from their homes,
but cautioned to exercise
good clinical judgment
 Same is true today with
COVID-19 as well
 Not time to throw out the
rule book
reserved.

Boundaries of
Competence
Who are
you?
reserved.
 Technical
 Legal
 Ethical
 Clinical

Home-Based Ethical Issues
BOUNDARIES:
 You may inadvertently violate your own
boundaries
 Noises / sounds (spouse yelling at
children)
 Children / adults in background,
seen through windows, doors
 Personal items visible in background
reserved.

Home-Based Clinical Issues
Maintaining Consistency/Predictability
 Help clients/patients focus off your home to
thinking of your office
 Post an image of your office waiting room
 Post images of your furniture (chair, sofa,
desk)
 Include office décor in your background
(picture, vase, etc.)
 Keep reins on your starting/ending times
reserved.

 Keeps things quiet at home
 Play ambient music very softly
 Ask them if it bothers them
 Be extra cautious about comments regarding
your home or family
 If your doorbell rings, only respond if you
suspect an emergency
 Let the sign on your door direct them
reserved.

 Keep the focus on them
 Develop a 1-line response to deal with
normal curiosity about your home life
 Use the same line repeatedly and
did no diverge
 They will get the message
reserved.

Maintaining Your Therapeutic Frame
 Don’t deny someone’s reality by lying
about:
 what you just did
 what they just saw
 Own it and deal with whatever comes
next
 Be yourself
reserved.

Boundaries Are Key
 You may forget to notify family and
friends of your professional appointment
schedule – they may unknowingly
interrupt your professional time
 You may be flustered when dealing with
an emergency because you have not
practiced coping with crisis when using
technology. Best to “practice” with
colleagues and not clients and patients
reserved.

Procedures Are Also Key
 Start a session with an opening protocol
 That protocol includes formal procedures
to secure both ends of the meeting
Ask your client/patient to identify
themselves if you don’t know thm well
As where they are
Ask them to scan room with camera if
needed

Procedures Are Also Key
 Develop a non-verbal, fail-proof system to notify family or
friends when you are in session
Lock your home office door
“Do not disturb” note on door
Note on kitchen counter
Text message others
Turn your camera away from the door

Video
“Ooopsies”
 Cameras may show
your more than you see
on your end
 Clean your background
all the way to the
corners of your room
 Test with family/friends
 Prepare a response if
someone comments on
what they see

Background
Distractions
Get Amplified
Busy Streets,
Telephones, Faxes,
Televisions, Radios,
Stairs, Kitchen,
Vacuums,
Trains/Airplanes,
Doorbells, Children
and Teens

Clinical Issues &
Production Values
v Avoid:
v “ One-eyeball Effect”
v Showing Your Client the
Inside of Your Nose
v Messy Backgrounds
v Noisy Children, Spouses,
Curious Cats or a Barking
Dog(s)
v Doorbells (put sign on door)

Stretching Your Comfort Zone
 Stretching is needed, but don’t over-do
 Master one thing at a time
 Avoid multiple platforms, devices, apps,
etc.
 Find a 1-stop shop to deal with several of
your tech needs
reserved.

Telehealth Guidelines?
 The American Telemedicine Association and
the America Psychological Association
published Telepsychology Guidelines in 2013
 NASW and other groups published a
guideline in 2017
 American Psychiatric Association in
conjunction with American telemedicine
Association published guidelines in 2019
 Reading a guideline does not establish
competence

https://www.apa.org/practice/guidelines/telepsychology

Do we really need special
telehealth training?
 Competence in behavioral health is NOT equivalent to
competence as a telebehavioral health professional
 All ethical codes require competence in our
professional practices

Do we really need special
telehealth training?
 Competencies have since been published in
telebehavioral health.
 You can download a free copy here:
 https://telehealth.org/blog/an-interprofessional-
framework-for-telebehavioral-health-competencies/
 Download a FREE copy, and consider whether you
can do what is expected of you as a professional

Telepresence
(TBH Domain IV)

Results: From a total of 4,712 potential
references, 453 were eligible for full
text review and 77 papers directly
related to the concepts.
From papers’ references and a review
of books and popular literature, 12
other sources of information about TPr
and VR were found. Though few
studies literally discuss the
therapeutic relationship, the impact
of technology on clinical
engagement and communication is
growing, from clinical (e.g.,
psychotherapy) and non-clinical (e.g.,
communication, TPr) literature.
Impact of
technology on
therapeutic
relationship

Avoid
Distractions
The historical evolution of TPr and VR
shows that definitions, foci of studies
… and assessments vary widely. TP
and TBH care can be improved by
concepts of TPr, avoiding
distractions, understanding the
technology-human interface,
measures of TPR for clinical use and
the use of simulation for training.
Reference: Hilty DM, Randhawa K, Maheu
MM, McKean AJS, Pantera R. Therapeutic
relationship of telepsychiatry and
telebehavioral health: Ideas from research on
telepresence, virtual reality and augmented
reality Psychol Cogn Sci Open J. 1994-2020;
5(1): 14-29. doi: 10.17140/PCSOJ-5-145

Technology Choices
(TBH Domain III)

Clinical &
Technical Issues
 Audio Clarity & Continuity
 Equipment Quality
Type of Microphone
Headsets
Free Standing
Microphone Placement
Type of Speaker
Speaker Location
 Minimize Distractions

Variations in Connectivity
When at Home
 Commercial vs. residential connectivity
 Differences in bandwidth
 Bandwidth speed can also differ by time of
day. After school is often a high traffic time
and Internet speed can be significantly
slower.

reserved.

 Some people are uncomfortable
with technology
 Different technologies are better for
specific tasks

Difficult to stay focused
with the telephone for
long meetings. Easy to
get bored or distracted.
Video is better to keep
parties engaged.

Can’t blame the technology company, the Internet,
or the fact that you didn’t know better.
reserved.
The
responsibility
is on your
shoulders

Ignorance is not a defense
in the face of the law
reserved.
The
responsibility
is on your
shoulders

Legal Issues of
Relevance when
Working from Home

Temporary
Relaxing of
HIPAA vs
Privacy
Requirements
reserved.
We are in a state of
international emergency
Laws are getting
relaxed, just as they
would be in a hurricane
HIPAA is being relaxed
in some very specific
ways

How do you establish
competence?
 Education/Training
 Supervision
 Experience / Self-instruction
 Documentation
 Informed Consent
 Intake forms
 Progress notes
 Termination notes
 Risk assessments
 Referrals

Basic Telehealth Legal Errors
 Billing inaccurately (insurance fraud)
 Wrong licensure (practicing without a
license)
 Practicing anonymously (precludes
mandated reporting)
 No continuity of care
 Wrong technology (privacy, security,
data integrity) HIPAA and HITECH)
reserved.

Temporary
Relaxing of
HIPAA versus
Legal and
Ethical
Privacy
Requirements
reserved.
It is our job to know the laws,
and only relax the ones that we
MUST relax
State laws and ethical principles
related to privacy (and other
areas) are not going out the
window
They will hopefully change, but
we must assume that they were
put into place to protect citizens
and most of them will go back
into effect post-COVID-19

HIPAA
COVID-
19
 https://www.hhs.gov/hi
paa/for-
professionals/special-
topics/emergency-
preparedness/notificati
on-enforcement-
discretion-
telehealth/index.html

HIPAA Rules
HIPAA rules are being relaxed by
the Department of Health &
Human Services
 Ok to speak with other
professionals without explicit
release form
 Traditional HIPAA discussions
with clients/patients have
included this basic permission
for decades anyway.
HIPAA basics
should be in
place

HIPAA COVID-19 Update
Not impose penalties
for noncompliance
under good faith
provision of telehealth
Can use any non-
public facing remote
communication
product during during
COVID-19 emergency

Can use audio or
video and applies
to telehealth
provided for any
reason
Assess or treat any
other medical
condition, even if
not related to
COVID-19

Notify patients that
these third-party
applications
potentially introduce
privacy risks
Use all available
encryption and
privacy modes when
using such
applications

•For added protections,
these are some options
of HIPAA-Compliant
services
Skype for Business,
Updox, Vsee, Zoom
for Healthcare,
Doxy.me, Google G
Suite Hangouts Meet

•Some public-facing
video technologies
should not be used
Facebook Live, Twitch,
TikTok, and similar
video communication
applications are public
facing, and
should not be used

Temporary
Relaxing of
HIPAA vs
Privacy
Requirements
reserved.
Only release what you
MUST release
Laws have been slow
to change
Basic safety
protections will return

What does COVID-19
mean for your work?
The clinical ramifications of giving increased access to you
through technology must be weighed with a risk
assessment of the person in question.
1. What is their diagnosis?
2. What does that diagnosis tell you about their ability to
push any boundaries that you wish to put into place with
technology after the current situation subsides?
3. Can you expect compliance?

What does COVID-19
mean for your work?
 Consider video conferencing
 You may also want to consider any communication
channel that you determine to be necessary to keep
people safe
 If you choose to proceed, advise your clients and
patients that rules have been lifted temporarily, much
as they would be in a flood zone or other natural
disaster experiencing an emergency

What does COVID-19
mean for your work?
Options Beyond Video Conferencing
 Send emails to keep everyone informed? If yes, email the
message to yourself, and BCC your intended recipients so
they won’t see each other on the TO: line of your email
 Communicate with your clients and patients in unsecured
text messaging already built into your devices? If yes, think
about what you write, how it might be mis-interpreted, and
document your communications.

What does COVID-19
mean for your work?
Options Beyond Video Conferencing
 Unencrypted text messages either reside on your SIM
card or in the circuitry of the mobile phone. Messages
then, can be discovered later and given from one party to
another through the hardware of the phone.
 Point: be judicious about what you say
 Avoid LOL, emoticon, memes, etc.
 Maintain your professional boundary at all times

What does COVID-19
mean for your work?
I’m not a lawyer, but given the circumstance, a
reasonable way to proceed could be:
1. Consider diagnosis, risk analysis, history, living
situation, physical health and make your
determination for each person individually
2. Give your patients or client dynamic informed
consent about risks and benefits
3. Document rationale and time/day of IC
4. Carry on

Join Your National, State,
Provincial or County
Psychological Associations
 It is time to connect with both
our national and local
professional communities
 Get on their mailing lists
 Give them a hand if you have
time

https://www.n
aadac.org/cov
id-19-
resources

Licensing
Boards
 Licensing laws are in flux
 Usually, you have to be
licensed where you client
or patient is at the time of
the contact
 NOW - Check with your
state board’s website
 Get on any mailing lists
 Check the Center for
Connected Health Policy
reserved.

https://www.cchpca.org/

California
Psychological
Association
Email News
March 18, 1994-
2020

CALIFORNIA Department of Managed
Health Care (DMHC) is requiring all
[insurance health] plans to reimburse for
telehealth at the same level they
reimburse for face-to-face visits.

What are
traditional
telehealth
jurisdictional
limitations?
 Licensing laws are in flux.
 To comply with licensing
law, you must traditionally
be licensed in the state (or
province) where your
client/patient is at the time
of the contact, regardless of
where you live or work.
 Much telehealth is
conducted by practitioners
in their home offices.
reserved.

Telepsychology 50-State Review
http://www.apapracticecentral.org/advocacy/state/telehealth-slides.pdf
reserved.

How to handle?
 Realize that employer,
insurance company and
other forms are legal
declarations
 Always tell the truth
 Always inform your
malpractice carrier

Ethical Issues

Telebehavioral Health
Standards & Guidelines
 American Medical Association
 American Counseling Association
 American Mental Health Counselors Association
 American Psychological Association
 American Telemedicine Association
 Australian Psychological Society
 British Psychological Society
 Canadian Psychological Association
reserved.

Telebehavioral Health
Standards & Guidelines
 Federation of State Medical Boards
 National Association of Social Workers
 New Zealand Psychological Psychologists Board
 Ohio Psychological Association
 For specific documents, see:
http://telehealth.org/ethical-statements
reserved.

Informed Consent
reserved.

Informed Consent Issues
IC is Not Directly Relevant in Home-Based
Telehealth Delivery
 IC is a legal as well as ethical issue
 Most state laws and ethical codes do
not ask you to describe where you are
at any given time when using
telehealth
 If you mention it however, you will
need to deal with consequences as a
therapeutic boundary issue
reserved.

Reimbursement

COVID-19 Funding
 Changes affect Medicare, Medicaid and in some states,
the 3rd party payors.
 See handout by the Center for Medicare and Medicaid
Services (CMS)
 So far, communication equipment must provide 2-way,
live interactive video. Telephone is not yet covered,
although APA is advocating for telephone to be
approved
reserved.

Coronavirus Preparedness and
Response Supplemental
Appropriations Act 1994-2020
 The new law limits telehealth services to patients for
whom the provider had filed a Medicare claim for
within the previous three years. However, CMS
guidance states that the Department of Health and
Human Services (HHS) will not conduct audits to
check whether a clinician’session was a new or a
returning patient.

 Medicare patients are no longer required to be in
an originating site and can now receive telehealth
services in their own homes as well as in any
health-care facility.
 Telehealth is now available to Medicare
beneficiaries in all parts of the country, not just in
rural areas.

 Telehealth services are reimbursed for the
same dollar amount as in-person visits.
 Providers may reduce or waive cost-sharing
for telehealth visits during this emergency
period. This does not apply to brief
communication e-Visits (described below).

Reimbursement
Medicare
Bill Medicare for
telehealth services the
same way you bill for an
office visit by using the
appropriate CPT® code
for the service provided.

CPT Codes
 Interactive complexity (90785)
 Psychiatric diagnostic interview (90791)
 Psychotherapy including individual (90832, -34, -37), family
(90846, -47), and
 Psychotherapy for crisis (90839, -40)
 Psychoanalysis (90845)
 Health behavior assessment and intervention services,
individual and group (96158, -59, -64, -65, -67, -68, -70, –71)
 Neurobehavioral status examination (96116, 96121)

Telehealth Modifier Codes
“95” IS NEW
STANDARD CPT
CODE
“02” IS USED FOR
PLACE OF SERVICE
(POS)

E-visits
Medicare co-insurance
and deductible amounts
cannot be waived for e-
Visits.
Brief communication,
typically initiated by the
patient, and can be
furnished in any location
or geographic area.

https://www.apaservices.org/practice/reimbursement/h
ealth-codes/online-assessment-management-services

Questions?
Marlene M. Maheu,
PhD
Executive Director
Telebehavioral
Health Institute, LLC
contact@
telehealth.org
619-255-2788

COVID-19 Telehealth Best Practices

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